Date____________                                           Fee $_______________

Property address _______________________ Tax account #______________________

Zoning District_____________ Property also known as:__________________________

Property owner(s) _____________________________________

_____________________________________

Owner's address ________________________________ Telephone ____________(day)

________________________________                                             ____________(evening)

Applicant __________________________________

Applicant's address_______________________________Telephone____________(day)

________________________________                                            ____________(evening)

Applicant is: ____owner ____lessee/tenant ____agent _____other:____________

Application for: _______Area Variance _____Special Exception Use
_______Use Variance _____Temporary Zoning Permit
_______other (describe):_______________________________

Application Information:

1) This application is for relief from or pursuant to Chapter(s)______________________
_____________________________________ of the Code of the Village of Pittsford.
Building Inspector's denial dated_____________is attached.

2) Description of variance or other relief sought:_________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

3) All facts showing the necessity for relief:_____________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

4) Difficulties or hardship that would result if this application is denied:________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

5) The following items are attached and are part of this application:__________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Owner's Statement

I am the owner of the above property, and have read and approve this application. If the applicant
is other than the owner, I authorize the applicant to proceed as agent.

Signature_______________________________ Date_____________

Applicant's Statement

I hereby certify that the information submitted is, to the best of my knowledge, true and correct.

Signature________________________________Date_____________

FOR OFFICE USE ONLY
Public Hearing sign(s) given to applicant___________
Notice of Public Hearing published___________
Neighborhood notification mailed____________
Referral to Monroe Co. Planning: yes ____(date)________no ____
Hearing date(s)__________________________
Date of ZBA action_______________________
Approved__________ Approved w/conditions_________ Denied__________
Date of filing of decision________________